Ophthalmic emergencies, Mr K Lett (PPTX, 2.43 MB)
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Transcript Ophthalmic emergencies, Mr K Lett (PPTX, 2.43 MB)
Mr. Kim Son Lett
Consultant Ophthalmologist & Vitreo-Retinal Surgeon
Birmingham & Midland Eye Centre & BMI The Priory
Pre-Triage System
Red
Need to be seen within a few hrs, further triaging.
Amber Need to be seen within 72 hrs, diverted to UCC
slots.
Green No need for urgent assessment, referred to GP,
optometrist or to OPD (via GP).
v
Red – Very Urgent
Penetrating eye injury
Acute post-op endophthalmitis
Severe chemical injury
Orbital cellulitis
GCA with visual symptoms
Sudden loss of vision <6hrs
v
Red - Urgent
Painful red eye with visual loss
Retinal detachment with good VA
Corneal ulcer, esp. with CL wear
Blunt trauma with hyphaema & ↑ IOP
Corneal graft rejection
Painful diplopia
v
Amber
Flashes & floaters, no loss of vision
Red eye without pain or visual loss
Retinal vein occlusions (OPD 4-6/52)
Diabetic retinopathy with vitreous haemorrhage
Wet AMD (preferably refer to Fast Track Macular Clinic)
v
Green – GP / Optometrist Mx
Bacterial & viral conjunctivitis
Allergic conjunctivitis
Blepharitis
Dry eyes
Lid lumps and bumps
v
Green – OPD Referral
Cataract
Chronic / gradual visual loss (months)
Open angle glaucoma, ocular hypertension
Watery eyes
Ectropion, entropion
Lid lumps & bumps
v
Non-acute diplopia
Trauma
Burns
Acid, alkali, thermal, arc eye
Abrasions & lacerations
Lid, corneal and conjunctival, Penetrating Eye Injuries
Foreign bodies
Corneal, conjunctival, sub-tarsal, intra-ocular
Blunt trauma
v
Sub-conjunctival haemorrhage, hyphaema, choroidal rupture
Orbital Blowout Fracture, Traumatic Optic Neuropathy
Chemical Injury
Emergency
Alkali or Acid
pH check
Immediate irrigation
v
May result in limbal stem cell
failure
Corneal Abrasion
History provides diagnosis &
indication of severity
Mostly doesn’t require A & E
Oc. Chloramphenicol qid 5/7
v
Foreign Bodies
Can be removed if confident
g. Chlor qid 5/7
Refer (PEARS?) if unable to
remove or rust rings
Always check for subtarsal FB v
as well
Sub-conjunctival Haemorrhage
Spontaneous vs traumatic
Self limiting
No treatment
No referral required
v
Blow Out Fracture
Assess for globe damage,
Traumatic Optic Neuropathy
Orbital surgery only if tissue
entrapment
Normally performed within
4/52
v
Cornea
Dry eye
Recurrent erosion syndrome
Ulcers
CL related
Acanthamoeba
Dendritic
Shingles
v
Dry Eyes
Lubricants
Look for blepharitis
Refer OPD only if unable to
improve symptoms
v
Recurrent Corneal Erosion
H/O Index injury
Typically pain on waking /
opening eyes
Oc. Simple / Lacrilube nocte
3/12
Refer OPD if no improvement
v
Bacterial Keratitis
Esp in CL wearers
Excess wear, poor hygiene
Urgent referral
Differentiate from marginal
keratitis
v
Dendritic Ulcer
Typically HSV 1, as with cold
sores
Self limiting
Treat with topical Acyclovir /
Valgancyclovir 5x/d, 7/7
UCC referral
v
Herpes Zoster Ophthalmicus
Oral antiviral Rx if started
within 72hrs onset of rash
Not always eye involvement
Hutchinson’s sign
70% chance eye involvement
Most eye involvement doesn’t
require specialist Rx
v
Conjunctiva
Conjunctivitis
Bacterial, viral, allergic
Episcleritis
Scleritis
v
Bacterial Conjunctivitis
Purulent / mucopurulent
discharge
Self limiting
OTC g. Chlor qid 1/52
No referral required
v
Viral Conjunctivitis
Watery discharge
Follicular reaction
Self limiting
No referral required unless
corneal involvement
v
Allergic Conjunctivitis
Identification and avoidance of
trigger allergen
Topical Sodium cromoglycate
Oral anti-histamines
No referral required unless
persistent problem
v
Episcleritis
Self limiting
Mild – Moderate discomfort
Oral NSAIDs, eg ibuprofen
No referral required unless
persistence
Steroid dependency
v
Scleritis
Severe dull boring pain
Brawny red appearance
Strong association with autoimmune and connective tissue
disease
Urgent referral
Needs extensive management
v
Lids
Blepharitis
Anterior, posterior
Chalazion, stye
Ectropion, entropion
Pre-septal cellulitis
v
Anterior & Posterior Blepharitis
Lid hygiene
Hot compresses
Treat associated dry eye
No referral required
v
Chalazion
Hot compresses
I&C if refractory
Prescribe oral Abx if infected
No referral to A & E
v
Senile Ectropion & Entropion
Ensure lubrication of ocular
surface
No acute management in
A&E
Refer routinely
v
Pre-Septal Cellulitis
Need to differentiate with
orbital cellulitis
Pt not systemically unwell
No orbital signs
Needs oral Abx (GP)
Refer if in doubt
v
Orbital Cellulitis
Potentially sight / life
threatening condition
Pt systemically unwell, pyrexial
Orbital signs
Emergency referral
Need admission and IV ABx
v
Neuro-ophthalmology
IIIrd, IVth, VIth nerve palsies
Optic neuritis
Papilloedema
Giant cell arteritis
v
3rd, 4th, 6th Palsy
Majority will be microvascular
in elderly diabetic hypertensive
population
Consider duration
Beware of painful nerve palsy
esp 3rd PCA aneurysm
Beware of assoc headache
esp 6th GCA
v
Disc Swelling
Physiological
Hypermetropes
Optic cup
SVP
Vessel changes
Exudates
Haemorrhages
Hyperaemia
Retinal folds
VISUAL SYMPTOMS?
v
Optic Neuritis
Mostly due to demyelination
Unilateral vs bilateral
Child vs adult
2/52 ↓, 2/52 ↔, 2/52 ↑
Reduced vision, colour vision,
RAPD
Uhtoff’s phenomenon
Pain esp ocular movement
Haemorrhages
Hyperaemia
Venous distension
Swelling
Or no physical signs
v
Papilloedema
Due to raised ICP
Bilateral
Reduced vision
Obscurations
Blind spot enlargement
Haems
Hyperaemia
Tortuous congested vessels
Exudates
Cup obliteration
Retinal folds
v
Giant Cell Arteritis
Temporal headache and
tenderness
Blurred vision
Jaw claudication
Polymyalgia
Associated with RAOs
Emergency referral to Eye Cas
ONLY if visual symptoms eg.
v
Amaurosis
Otherwise refer urgently to
Rheumatology / Physicians
Glaucoma
Open vs Closed angle
1̊ vs 2̊
Neovascular
What IOP is urgent?
<30mmHg refer to outpatients
>30mmHg D/W on call team
v
Acute Angle Closure Glaucoma
Typically presents midday
onwards
Fixed, semi-dilated pupil
High pressure, corneal
oedema
Closed angle – may need to
examine fellow eye
Emergency referral
Needs medical treatment then
laser iridotomy
More extensive surgery may
be necessary
v
Vitreo & Medical Retina
Posterior Vitreous Detachment
Vitreous haemorrhage
Retinal tears and holes
Retinal detachment
Wet AMD
Vascular occlusions
v
Proliferative diabetic retinopathy
Posterior Vitreous Detachment
Only 30-50% PVD
symptomatic
Symptomatic PVD refer to
UCC, depending on duration
Most are not associated with
retinal detachment
v
Vitreous Haemorrhage
Check for systemic
associations eg. DM, HT,
Sickle
Examine fellow eye
If present, UCC referral
(duration dependent)
In absence of systemic
disease, PVD with VH has
70% incidence of retinal tear
Urgent referral to Eye Cas
v
Retinal Detachment
Is the macula on or off?
VA
Clinical exam
If on, emergency referral
If off, Eye Cas, UCC or clinic
depending on duration
Check for symptoms of
chronicity
NOT ALL DETACHMENTS
ARE AN EMERGENCY!
v
Wet Macular Degeneration
Sudden onset reduction of
vision, distortion
H/O dry AMD
Optician can diagnose
Fast track macular service
v
Venous Occlusions
No emergency treatment
available
Refer via fast track system
Need long term treatment
v
Arterial Occlusions
Irreversible retinal damage
from 4hrs of onset
Immediate emergency
treatment up to 8hrs from
onset
Aspirin
ocular massage
rebreathing into bag
Beyond this time no heroic
measures
Check for GCA symptoms
Stroke/TIA pathway
v
Proliferative Retinopathy
Most commonly diabetics
Also Sickle, prior RVOs and
rarely RAOs
Refer to UCC unless also VH
v
The Future
6-9% annual increase in demand
<30% of attenders are genuine 4hr cases
PEARS / MECS
Rapid access clinics
Allied professionals in house
Nurses
Optometrists
Orthoptists
v
GP surgeries open all hours!